One of the major components of any trauma system is the prehospital piece. These providers extricate, begin medical treatment, and decide where to take the patient. The choice of hospital can make a big difference, and the number of deaths can potentially be reduced by up to 25% by making the right decision. Where to take the patient is not necessarily clear cut, even though CDC guidelines exist to help. Geographic and weather factors can be a factor, as well as patient choice at times (unfortunately), local medical control, or even time of day (traffic).
Harborview and the University of Washington conducted a large retrospective review of the transport patterns for nearly 12,000 injured patients over a 5 year period. They specifically looked at whether CDC guidelines for field triage were being followed. About half were transported to Harborview, the only Level I center in the state. The remainder were transported to the 7 remaining trauma centers, levels III to V. There were a number of interesting findings:
- Patients transported directly to the Level I center were more likely to be young, male, injured by a penetrating mechanism, have worse vital signs and GCS and higher injury severity
- Older patients were less likely to be transported from scene to a Level I center
- The oldest patients were 89% less likely to be transported to the Level I center, either directly or after initial management at a lower level center
Bottom line: For reasons that are not clear, elderly patients were far less likely to be transported to a Level I trauma center by prehospital providers in Washington state. In fact, the guidelines were obeyed only about 50% of the time! Does this happen in other states or countries? We don’t know. Is this a problem? Unfortunately, we also don’t know how much lower the mortality in these patients is when treated at higher level centers. It seems to be, especially in the more severely injured patients. What we do know is that if the guidelines exist, adhere to them unless you have good reason not to. Their life may depend on it!
- Benefit of transport to a trauma center
- Wallet biopsy when transferring to trauma centers
- CDC Triage guidelines app
Reference: Compliance with Centers for Disease Control and Prevention field triage guidelines in an established trauma system. J Amer Col Surg 215(1):148-156, 2012.